Opioid Error in Paediatric Hospital Practice

Last modified by Samantha DeLenardo on 2014/07/09 16:09


Safe, effective and focused use of opioids in paediatric hospital practice has arguably never been more complex than it is today. Opioids are the most common pharmacologic agents used to treat moderate to severe pain, but opioid errors are the most frequent source of medication-related harm in pediatric practice.

Internal data from the Hospital for Sick Children shows that morphine is three times more likely to be involved in an incident report than the second most reported drug (heparin)(1.41 reports/1000 patient days vs 0.43 reports/1000 patient days). Additionally, the Institute for Safe Medication Practices (ISMP) Canada has listed morphine as the number one drug causing patient harm, primarily from drug errors.

Our aim is to significantly improve all phases of the opioid medication process in order to maximize the efficacy and safety of opioids in paediatric care. This presentation will describe the quantification and qualification of contributing factors to opioid error in paediatric hospital patients, and will identify strategies to reduce risk.



Renu Roy

Renu graduated from the University of Saskatchewan, College of Pharmacy, and has held a variety of positions at SickKids, including clinical pharmacist in General Paediatrics and Cardiology, and Drug Information Pharmacist. Currently, she is the Medication Safety Pharmacist with the role of promoting and enhancing safe medication practices at all levels of the medication use process. Renu is the co-chair of the hospital’s Medication Safety Committee whose mandate is to provide oversight and leadership for the development of safety improvement initiatives focused on opioids and other high-alert medications. She is currently pursuing her MSc in Quality Improvement and Patient Safety at the University of Toronto’s Institute of Health Policy, Management, and Evaluation.

Dr Conor Mc Donnell

Conor is a Staff Anesthesiologist at the Hospital for Sick Children, Toronto. He is also an investigator for SickKids Research Institute, the Director of Quality & Patient Safety for Anesthesia, and, co-chair for the Hospital’s Medication Safety Committee. Previous relevant research publications include manuscripts on opioid error and tenfold medication error in paediatric hospital practice. In collaboration with Ms Roy, current ongoing projects address paediatric medication safety with special focus on high risk medication error.

Created by Lisa Stromquist on 2014/06/20 18:39